MAUDE Adverse Event Report: ETHICON INC. PHYSIOMESH COMPOSITE MESH 7X15CM RECT; MESH, SURGICAL

Catalog Number	PHY0715R
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Not Applicable (3189)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).To date, the device has not been returned.If the product is returned for evaluation, any further information derived from the evaluation will be submitted in a supplemental 3500a form.
Event or Problem Description
It was reported by an attorney that the patient underwent a hernia repair procedure on (b)(6) 2013 and two mesh products were implanted.It was reported that the patient underwent a hernia repair procedure on (b)(6) 2014 and another mesh was implanted.It was reported the patient experienced an undisclosed adverse event.Other impacted products were captured in separate files.No additional information was provided.
Additional Manufacturer Narrative
Date sent to the fda: 4/09/2025.D4: udi: as the lot number for the device involved in the event was for dhr review, the full udi is currently not available.Additional information: a2, d1, d2a, d3, d4(catalog, lot, primary udi#).This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information prior to the required reporting date.This report does not reflect a conclusion by ethicon, or its employees that the report constitutes an admission that the product, ethicon, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.
Additional Manufacturer Narrative
Date sent to the fda: 4/21/2025.Additional information: d4 (expiration), h4.Corrected information: d4 (primary udi #).A review of the batch manufacturing records was conducted and the batch met all finished goods release criteria.This report is being submitted pursuant to the provisions of 21 cfr, part 803.This report may be based on information prior to the required reporting date.This report does not reflect a conclusion by ethicon, or its employees that the report constitutes an admission that the product, ethicon, or its employees caused or contributed to the potential event described in this report.If information is obtained that was not available for the initial report, a follow-up report will be filed as appropriate.

• Brand Name: PHYSIOMESH COMPOSITE MESH 7X15CM RECT
• Common Device Name: MESH, SURGICAL
• Manufacturer (Section D): ETHICON INC.; 1000 route 202; raritan NJ 08876 0151
• Manufacturer (Section G): ETHICON INC.-GMBH; p.o. box 1409; norderstedt D2284 1; GM D22841
• Manufacturer Contact: darlene kyle ; p.o. box 151, route 22 west; somerville, NJ 08876-0151 ; 9082182792
• MDR Report Key: 9114529
• Report Number: 2210968-2019-88026
• Device Sequence Number: 1776459
• Product Code: FTL
• UDI-Device Identifier: 10705031132290
• UDI-Public: (01)10705031132290(17)150228(10)GC8GPKAO
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K093932
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 09/19/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 02/28/2015
• Device Catalogue Number: PHY0715R
• Device Lot Number: GC8GPKAO
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 09/17/2019
• Supplement Date Received by Manufacturer: 04/03/2025; 04/04/2025
• Initial Report FDA Received Date: 09/25/2019
• Supplement Report FDA Received Date: 04/09/2025; 04/22/2025
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 03/18/2013
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Female